Exoskeleton Rehabilitation for Complete Thoracic Spinal Cord Lesion: A Case Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors evaluated the effectivity of exoskeleton training in chronic spinal cord injury. The introduction is missleading in that extent, recovering walking ability (regardless of supportive technology adapted) after a chronic spinal cord injury is not feasible currently. This should be clarifyed. The cited reference nr 3, reflects to the possibility of recovery mainly due to decresed edema, and diaschisis appeares in the acue - post acute intervall after injury. The exoskelton therapy has many adantages, but in complete SCI should serve as a replacement for wheelchairs to increase the QoL of clients in partly adapted environment. Please amend the text accordingly.

The paper is well structured, although a more comprehensive and objective evaluation is scarce and should be improved. The functional state of the patient was not evaluated objectively (FIM, FAC), which is a major missing point. 

Considering the senasional results, was any objective measure taken? Quantitative sensory testing, MRI or SSEP? Also, was sensation tested before the study? Considering ASIA A or B, the main difference is the (at least partly) preserved sensation in S2-5, however the manuscript suggests, sensation was regained, which means the classification improved, but this should be explained with mechanisms. 

Based on the time since injury, was osteoporosis assessed in any way? The newly developed sensation and crump could be due to a stretch fracture evoked by the intensive training on the porotic bone, and considering patient's safety should be throughtly checked. 

Overall, the topic is very important and evaluates important questions in this vulnarable population but due to the lack of objective measurements, the focus of the manuscripts should be transferred to a "QoL and well-being" focus instead of functional mobility of SCI patients. 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript describes a single-case study of an adult female with a chronic, complete thoracic spinal cord injury (SCI) who participated in a multi-modal rehabilitation protocol involving both traditional and robotic exoskeletons. The intervention consisted of regular, multi-component sessions spanning six months and was guided by both physiological and patient-centric outcome assessments. The study highlights subjective improvements in deep limb sensations and presents a thematic analysis mapping the patient’s perspectives to the WHO International Classification of Functioning, Disability, and Health framework.

            The report adds to sparse but growing literature on exoskeleton rehabilitation in chronic, complete SCI, with a rare focus on deep sensation restoration. While this is an understudied domain, mechanistic explanations remain speculative and require confirmation in larger, controlled studies. The case supports the provision of hope and tailored rehabilitation even in so-called “no rehab potential” patients, advocating for patient-centered approaches and use of advanced technology even years post-injury.

Specific Comments

• While the case report criteria are met, the generalizability of the findings is limited to this specific patient, making it challenging to inform broader practice or draw causal inferences.
• There is an absence of quantitative sensorimotor outcomes (e.g., electrophysiology, standardized sensory scales, neuroimaging) to substantiate the reported deep sensory change; all results are subjective.
• The patient’s improvement in sensation may be influenced by factors such as motivation, placebo effect, or undetected residual lumbar pathways (i.e., not strictly “complete” lesion), as acknowledged in the discussion.
• Long-term functional outcomes, sustainability of any sensory benefit, and potential for true neuroplastic adaptation remain unaddressed.

• Methods are well-described, using CARE guidelines; however, documentation of baseline and post-intervention neurological examination or more granular functional metrics would enhance rigor.

• Add, if available, standardized outcome metrics, for example, ASIA sensory assessments pre/post, or validated patient-reported outcome measures.
• Expand briefly on strategies to mitigate bias (e.g., blinding of subjective outcome recording or triangulating with provider observations).
• Clarify whether any adverse events or safety issues occurred that could influence generalizability.
• In discussion, reinforce the limits and risks of overgeneralization, especially for non-thoracic or younger patients.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript improved, still the FIM values did not changed, which would have been nice to highlight to markedly decrease the false hope of the SCI patients.